• No results found

Metabolic Aspects of Phototherapy

N/A
N/A
Protected

Academic year: 2020

Share "Metabolic Aspects of Phototherapy"

Copied!
12
0
0

Loading.... (view fulltext now)

Full text

(1)

PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the American Academy of Pediatrics.

Metabolic

Aspects

of Phototherapy

Paul

Y.

K.

Wu,

MD,

Joan

E.

Hodgman,

MD,

Barry

V.

Kirkpatrick,

MD,

Nathaniel

B. White,

Jr,

M Phil,

and

Dolores

A.

Bryla,

MPH

From the Department of Pediatrics, University of Southern California School of Medicine,

LAC/USC Medical Center, Los Angeles; Department of Pediatrics, Medical College of

Virginia, Virginia Commonwealth University, Richmond, and Biometry Branch,

Epidemiology and Biometry Research Program, Nationallnstitute of Child Health and

Human Development, National Institutes of Health, Bethesda, Maryland

Recent

studies have shown that exposure to

non-ionizing radiant energy may induce physical and metabolic effects in the neonate. The effects include changes in body temperature37”#{176}5”#{176};- peripheral blood flow75”05”08; insensible water 10557576105; gas trointestinal (GI) tract motility; and nutrient, elec-trolyte, and water balances.4’76’’89”#{176} In an effort to evaluate the influence of intake of fluid and calories on neonatal jaundice and the efficacy of photother-apy, the metabolic data obtained from the National Institute of Child Health and Human Development

(NICHD) phototherapy study were analyzed. The results constitute the subject of this report.

MATERIALS

AND

METHODS

The data were collected from 1,339 infants en-rolled in the study from the six participating insti-tutions as described by Bryla.’8

Fluid

Intake

To determine whether the daily total fluid intake might affect total serum bilirubin levels, the data

were analyzed by dividing the control and photo-therapy-treated infants in each weight group into four subgroups according to their total daily intake. The subgroups are: A, <60 mL/kg/24 hours; B, 60 to 89 mL/kg/24 hours; C, 90 to 119 mL/kg/24 hours; and D, 120 mL/kg/24 hours.

The amount of total fluid intake used for char-acterization of the subgroups was determined

mi-tially by plotting all daily total intakes against total serum bilirubin levels for the corresponding day in a scattergram. The trend in clusters observed in the

scattergram was then used to designate the

amounts in the four subgroups.

Caloric Intake

To determine whether the mean daily total ca-loric intake might affect total serum bilirubin levels, the data were analyzed by separating the control and phototherapy-treated infants in each birth

weight group into three subgroups according to

their mean daily total caloric intake during the phototherapy period. The subgroups are: A, <60

calories/kg/24 hours; B, 60 to 90 calories/kg/24 hours; and C, >90 calories/kg/24 hours.

Additionally, the data were further analyzed ac-cording to intravenous and oral caloric intake sep-arately using the same three caloric subgroups (A, B, and C listed above).

Statistical

Analysis

Daily means for the phototherapy and control groups were compared using the t test for unpaired data. For comparison of subgroups (eg, fluids sub-groups A to D, and calories subgroups A to C), the analysis of variance procedure was used to compare the mean values of the variables (eg, total bilirubin

level, z bilirubin, 2-(4-hydroxyazobenzene)benzoic acid [HBABAJ binding).

RESULTS

Group

I (Birth

Weight

Less

Than

2,000

Grams)

(2)

TABLE 1.

Than 2,000

Relation of Daily Mean Total Serum Bilirubin Level to Fluid Intake for Infants

Grams, by Phototherapy (P) and Control (C) Groups*

with Birth Weight Less

Hours Into Study

Meati Total Serum Bilirubin Level (mg/dL)

Subgroup A Subgroup B Subgroup C

(<60 mL/kg/24 h) (60-89 mL/kg/24 h) (90-119 mL/kg/24 h)

Subgroup D (120 mL/kg/24 h)

P C P C P C P C

0 24 48 72 96 120 144

6.0 ± 1.9 5.4 ± 1.5#{176}5.7 ± 1.9 5.8 ± 2.4 5.9 ± 1.8 5.5 ± 1.8

6.8 ± 2 7.8 ± 1.6 6.5 ± 2.1” 8.3 ± 2.9” 6.0 ± 2.O’ 8.0 ± 2.5”

8.1 ± 2.5 10.6 ± 4.0 6.3 ± 2.1” 10.1 ± 3.1” 6.4 ± 2.8” 9.6 ± 3.3”

6.9 ± 3.2#{176} 12.9 ± 6.9#{176}7.1 ± 2.9” 11.4 ± 3.1” 6.2 ± 2#{149}6b 10.6 ± 3.3”

8.4 ± 5.3 9.4 ± 0.4 7.7 ± 2.4” 10.8 ± 3.4” 5.8 ± 2#{149}9b 10.9 ± 3.4”

7.7 ± 4.3 10.3 ± 2.1 9.0 ± 4.2 10.5 ± 5.1 7.3 ± 3.5” 10.8 ± 3.3”

7.6 ± 4.1 10.4 ± 5.1 7.2 ± 31b 9.2 ± 3.8”

5.7 ± 1.9 5.5 ± 2.1

6.3 ± 2.3k 75 2.6”

6.3 ± 2.4” 9.3 ± 3.2” 5.9 ± 2.6” 9.5 ± 3#{149}5b 5.5 ± 2.5” 9.1 ± 3.6” 5.9 ± 2.6” 8.3 ± 3.4” 6.1 ± 2#{149}9b 7.6 ± 34b * Values are means ± SD. Significance is indicated as follows:

a, P

< .05;

b, P

< .01. Blank spaces indicate that there were no infants in that fluid intake group for that day.

TABLE 2. Relation of Daily Mean Total Serum Bilirubin Level to Oral Caloric Intake

for Infants with Birth Weight Less Than 2,000 Grams, by Phototherapy (P) and Control

(C) Groups*

Hours Into Subgroup A Subgroup B Subgroup C

Study (<60 Calories/kg/24 h) (60-90 Calories/kg/24 h) (>90 Calories/kg/24 h)

P C P C P C

0 5.8 ± 1.8 5.6 ± 1.8 6.1 ± 2.2 5.6 ± 2.6 5.5 ± 1.6 5.5 ± 2.3

24 6.4 ± 2.0” 8.0 ± 2.6” 6.3 ± 2.3” 8.1 ± 26b 59 23b 7o 2.8”

48 6.7 ± 2.5” 10.0 ± 33b 6.3 ± 2.7” 9.8 ± 2.9” 6.0 ± 2.2” 8.5 ± 3.3”

72 6.3 ± 2.6” 10.6 ± 34b 6.4 ± 2.9” 10.5 ± 3.2” 5.7 ± 2.4” 8.8 ± 3.6”

96 6.6 ± 3.1” 10.9 ± 3.6” 5.6 ± 25b 10.3 ± 3.2” 5.2 ± 2.3” 8.4 ± 36b

120 7.7 ± 3.6” 11.1 ± 3.6” 6.7 ± 3#{149}0b 9.2 ± 3.3” 5.6 ± 2.4” 7.7 ± 3.4”

144 7.9 ± 3.6” 10.3 ± 3.9” 6.9 ± 3.2” 8.6 ± 3.7” 5.8 ± 26b 7o 3#{149}0b

* Values are means ± SD. Significance is indicated as follows:

b, P

< .01.

428 PHOTOTHERAPY FOR NEONATAL HYPERBILIRUBINEMIA

serum bilirubin level was similar in both control

and phototherapy-treated infants, with the excep-tion of the third day of phototherapy, when mean serum bilirubin level was lower in the photother-apy-treated infants. In all the subgroups with

higher fluid intake (B, C, D), the daily mean serum bilirubin level was significantly lower in the

pho-totherapy-treated infants during the phototherapy period compared with values in control infants

(P

< .01). During the postphototherapy period, the

daily mean serum bilirubin level was lower

(repre-senting lower rebound) in subgroups C and D in

the treated infants

(P

< .01).

There was a strong tendency for higher fluid intakes to be associated with lower daily serum bilirubin levels, in both phototherapy and control groups. However, the differences did not reach sta-tistical significance (Table 1).

Bilirubin

and

Caloric

Intake.

The relationship of the three caloric intake subgroups to daily mean

total serum bilirubin level is shown in Table 2. As expected, phototherapy-treated infants had signifi-cantly lower daily mean serum bilirubin

concentra-tions than control infants in all caloric subgroups. Higher caloric intake was associated with lower

serum bilirubin level in both control and

photo-therapy-treated infants based on Duncan’s multiple

range test. The effect of increased caloric intake on the lowering of mean serum bilirubin level was greater in the control infants than in the photo-therapy-treated infants.

In the immediately postphototherapy period (48

hours), control infants showed a continued steady

decrement in mean serum bilirubin level in all

caloric subgroups. Most phototherapy-treated

in-fants showed a rebound. The magnitude of the

rebound in serum bilirubin level was greater in infants with lower caloric intake than in infants with higher caloric intake.

To determine whether the observed differences in serum bilirubin levels associated with the differ-ent caloric intake subgroups were related to the route of caloric intake, the data were analyzed separately according to intravenous and oral caloric intake. Although there was a trend for higher intra-venous caloric intakes to be associated with lower serum bilirubin levels, the differences were not

statistically significant.

When the mean daily serum bilirubin was

ana-lyzed according to oral caloric intake subgroups, serum bilirubin was found to be inversely correlated to oral caloric intake in both phototherapy-treated

and control infants (Figure). The differences in mean serum bilirubin level between the caloric

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(3)

11 r

10

9

8

D)

E

z

-I

w U)

-I

I-0

I-z

Ui 7

6

5

4

LIGHTS OFF

1 I L I I

24 48 72 96 120 144

* Values are means ± SD. Significance is indicated as follows:

b, P

< .01. groups were more pronounced in control infants.

Interestingly, the mean serum bilirubin level in the infants in control group C (>90 calories/kg/24 h) was similar to the mean serum bilirubin level in

CAL/kg/24hr. A. <60

p

.- - --. CONTROL

B. 60-90

A -i PHOTOTHERAPY

#{163}-- - -a CONTROL C. >90

p p PHOTOTHERAPY

.-- --U CONTROL

HOURS ON STUDY

Figure.

Mean

changes (±SE) in daily serum bilirubin level relative to three oral caloric intake subgroups (A, B, and C). Note greater lowering of mean serum bilirubin level in subgroup C from subgroups A and B of control

infants compared with subgroup C from subgroups A and

B of phototherapy-treated infants.

phototherapy group A (<60 calories/kg/24 h) on the first and fifth day, and was significantly lower

on the sixth day of the study.

The relative decrement in bilirubin in photother-apy-treated infants was greatest in the first 24 hours, and the extent of decrement was directly

related to caloric intake. At the termination of phototherapy, the bilirubin level in the treated in-fants rebounded in all caloric subgroups. Higher

caloric intake was associated with a lower rebound in serum bilirubin (Table 2).

The mean peak serum bilirubin level was higher in control than in light-treated infants in all oral caloric subgroups

(P

< .01). Higher oral caloric intake was associated with lower peak bilirubin levels (Table 3). Thus, control subgroup C had significantly lower peak bilirubin level than sub-groups A and B

(P

< .05) and phototherapy sub-groups B and C had significantly lower peak bili-rubin level than subgroup A.

Although the day of peak serum bilirubin level occurred later in control than in light-treated in-fants (Table 4), the differences were only

signifi-cant between the subgroups with the highest caloric intake (C)

(P

< .05). The day of peak serum bili-rubin level was significantly earlier in subgroups B and C than subgroup A for both control and pho-totherapy-treated infants in the weight groups, 2,000 to 2,499 g and 2,500 g or more. However, in

the group with birth weight less than 2,000 g, only the phototherapy group with the highest caloric

intake (C) was significantly different from the low-est caloric group (A).

Stools.

During the phototherapy period, light-treated infants passed stools more frequently than control infants in all caloric intake subgroups (Ta-ble 5). During the postphototherapy period, the

frequency of stools was comparable in photother-apy-treated and control infants. In general, higher caloric intake was associated with more frequent

TABLE

First Fo

3. Relat

ur Days o

ion of Peak Serum Bilirubin Level to Average Oral Caloric Intake During f Study by Birth Weight, by Phototherapy (P) and Control (C) Groups*

Mean Peak Serum Bilirubin Level (mg/dL)

Birth Weight Birth Weight Birth Weight

<2,000 g 2,000-2,499 g 2,500 g

P C P C P C

Subgroup A

(<60 calories/ 8.4 ± 30b 11.7 ± 36b 14.4 ± 3.4 16.6 ± 4.4 15.4 ± 2.2” 18.0 ± 1.6”

kg/24 h)

Subgroup B

(60-90 calories/ 7.9 ± 2.5” n ± 3.1” 12.8 ± 1.6” 14.8 ± 2.8” 15.7 ± 2.5” 17.2 ± 2.5” kg/24 h)

Subgroup C

(4)

*

Values

are means

±

SD.

430

PHOTOTHERAPY

FOR

NEONATAL

HYPERBILIRUBINEMIA

TABLE 4.

Relation

of Day of Peak

Serum

Bilirubin

Level

to Average

Oral Caloric

Intake

During

First

Four

Days

of Study

by Birth

Weight,

by Phototherapy

(P) and

Control

(C)

Groups*

B irth Weight <2,000 g

Birth Weight 2,000-2,499 g

Bi rth Weight 2,500 g,

P C P C P C

Subgroup

A

(<60

calories/kg/24

h)

4.1 ± 2.3 4.1 ± 1.6 3.1 ± 2.4 3.5 ± 1.0 1.6 ± 0.8 2.5 ± 0.8

Subgroup

B

(60-90

calories/kg/

3.7

± 2.3 3.9 ± 1.3 1.2 ± 0.4” 3.0 ± 1.3” 1.3 ± 0.7” 1.8 ± 1.0”

24 h)

Subgroup

C

(>90

calories/kg/24

h)

2.9

± 1#{149}9b

39

1#{149}6b1.3 ± 0.7” 2.0 ± 10b 1.2 ± 0.5” 1.6 ± 0.7” *

Values

are means

±

SD. Significance

is indicated

as follows:

a, P

<

.05; b, P

<

.01.

TABLE

5.

Daily

Number

of

Stools

for

Infants

with

Birth

Weight

Less

Than

2,000

Grams,

by Phototherapy

and Control

Groups*

Hours Into Study

Phototherapy Group

Control Group

P

Value

0

3.3

±

2.1

2.4

± 0.7 <.01

24

3.8

± 1.7 2.7 ± 0.8 <.01

48

3.9

± 1.1 2.9 ± 0.8 <.01

72 3.6 ± 1.0 2.9 ± 0.8 <.01

96

3.3

±

0.9

2.7 ± 0.8 <.01

120

3.1

± 0.8 2.9 ± 0.8 NS

144

3.2

± 0.7 2.9 ± 0.7 NS

stools

in

both

phototherapy-treated

and

control

infants.

This

change

in frequency

with

higher

total

caloric

intake

was

entirely

associated

with

in-creased

oral

caloric

intake

as

use

of

intravenous

caloric

intake

had

no effect

on stool

frequency.

Body

Weight.

There

was

a strong

trend

for

light-treated

infants

to lose

more

weight

during

the

pho-totherapy

period

than

control

infants

during

the

corresponding

days.

During

the

postphototherapy

period,

light-treated

infants

gained

more

weight

than

control

infants.

The

same

trends

were

ob-served

when

the

data

were

analyzed

with

respect

to

oral

caloric

intake

using

Duncan’s

multiple

range

test.

Overall,

higher

oral

caloric

intake

was

associ-ated

with

decreased

weight

loss

or increased

weight

gain.

Group 2 (Birth Weight

2,000 to 2,499 Grams)

and

Group 3 (Birth Weight

2,500 Grams

or More)

Bilirubin

and

Fluid

Intake.

No

significant

differ-ences

in

daily

mean

serum

bilirubin

level

were

observed

between

control

and

phototherapy-treated

infants

in

the

two

lower

fluid

intake

subgroups.

However,

in infants

in the

two

higher

fluid

intake

subgroups,

the

same

trend

as found

in infants

with

birth

weight

ofless

than

2,000

g was

observed:

light-treated

infants

were

found

to have

statistically

sig-nificant

lower

daily

mean

serum

bilirubin

concen-tration

than

control

infants.

Higher

fluid

intakes

were

generally

associated

with

lower

serum

biliru-bin

levels

in both

phototherapy-treated

and

control

infants

(Tables

6 and

7). Mean

peak

bilirubin

level

and

day

of peak

were

not

related

to fluid

intake.

Bilirubin

and

Caloric

Intake.

In

all

caloric

sub-groups

in

these

weight

groups,

phototherapy-treated

infants

had

lower

mean

daily

serum

biliru-bin

than

control

infants

(Tables

8 and

9).

The

association

of

lower

serum

bilirubin

with

higher

caloric

intake

was

less

evident

than

in the

infants

in the

group

weighing

less

than

2,000

g. Significant

differences

in mean

daily

serum

bilirubin

level

were

only

observed

between

infants

in caloric

subgroups

A and

those

in subgroups

B and

C. In

contrast

to

infants

who

weighed

less

than

2,000

g, the

impact

of higher

caloric

intake

on lowering

serum

bilirubin

level

was

similar

in phototherapy-treated

and

con-trol

infants.

In

addition,

there

was

no

significant

rebound

in serum

bilirubin

level

following

cessation

of phototherapy.

Although

there

was

a strong

tend-ency

for

the

height

of peak

serum

bilirubin

level

and

day

of peak

to

correlate

inversely

with

total

caloric

intake,

significant

differences

were

found

only

between

subgroup

A and

subgroups

B and

C

(Tables

3 and

4).

When

the

relationship

of oral

caloric

intake

to

daily

mean

serum

bilirubin

level

in the

three

caloric

subgroups

was

examined,

no

significant

difference

in

serum

bilirubin

level

was

found

in association

with

different

oral

caloric

intakes.

Peak

serum

bil-irubin

level

and

day

of peak

were

also

similar

be-tween

the

three

oral

caloric

intake

subgroups.

Stools.

Light-treated

infants

tended

to pass

more

stools

during

the

phototherapy

period.

In the

period

after

phototherapy,

the

frequency

of

stools

was

comparable

in light-treated

and

control

infants.

In

contrast

to

group

1 infants,

there

was

no

relation

between

frequency

of stools

and

level

of peak

bili-rubin

or day

of peak,

probably

because

most

of the

infants

in this

group

entered

the

study

at their

peak

bilirubin

level.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(5)

TABLE

6.

Relation of Daily Mean Total Serum Bilirubin Level to Fluid Intake for Infants with Birth Weight of

2,000

to 2,499

Grams,

by Phototherapy

(P) and

Control

(C) Groups*

Hours Into Study

Subgroup A (<60 mL/kg/24 h)

P C

Subgroup B (60-89 mL/kg/24 h)

Subgroup C (90-119 mL/kg/24 h)

Subgroup D (120 mL/kg/24 h)

P C P C P C

0 24 48 72 96 120 144

14.0 5.7

12.5 ± 0.3 11.2

12.7 ± 2.1 13.2 ± 2.9 13.9 ± 5.7 12.7 ± 2.6 13.1 ± 1.9 12.2 ± 2.4

13.9 14.9 ± 4.2

6.6 ± 0.7 10.0 ± 1.4

11.8 ± 1.8 12.1 ± 1.5

11.3 ± 2.7” 14.1 ± 2.6” 10.1 ± 3.5” 15.5 ± 3#{149}8b

8.0 ± 2.4” 13.7 ± 3.7”

8.1 ± 3.6 9.9 ± 2.2

6.3 ± 1.5 9.2 ± 3.1

12.3 ± 1.8 12.8 ± 2.2

10.3 ± 2.1” 13.0 ± 24b 8.6 ± 2.9” 13.3 ± 2.8” 7.5 ± 2.4” 11.8 ± 2.9” 6.6 ± 2.3” 10.9 ± 6.6”

6.6 ± 2.4” 9.8 ± 2.9”

6.7 ± 7.0” 8.7 ± 2.6b

*

Values

are means

±

SD. Significance

is indicated

by: b, P

< .01. Blank spaces indicate that there were no infants in

that

fluid

intake

group

for that

day.

TABLE 7.

Relation

of Daily

Mean

Total

Serum

Bilirubin

Level

to Fluid

Intake

for Infants

with

Birth

Weight

of

2,500

Grams

or More,

by Phototherapy

(P) and Control

(C) Groups*

Hours Into Study

Subgroup A (<60 mL/kg/24 h)

Subgroup B (60-89 mL/kg/24 h)

Subgroup C (90-119 mL/kg/24 h)

Subgroup D (120 mL/kg/24 h)

P C P C P C P C

0 15.0 ± 2.0 16.0 ± 0.9 15.5 ± 2.7 16.1 ± 2.3 15.9 ± 2.7 15.4 ± 2.8 16.0 ± 2.4 15.6 ± 2.1

24 13.8 ± 1.1 12.2 14.0 ± 2.7#{176}17.2 ± 3.2a 13.2 ± 2.8” 15.1 ± 2.6” 13.5 ± 2.6” 15.0 ± 2.8b

48 13.7 ± 4.1 12.4 ± 4.2 11.6 ± 2.7” 14.2 ± 1.7” 10.8 ± 2.8” 13.2 ± 3.1”

72 8.8 ± 3.4#{176}13.0 ± 3.2#{176}9.1 ± 2.9” 11.8 ± 3.3”

96 6.0 ± 2.8 12.1 7.7 ± 2.9 11.0 ± 2.9 7.8 ± 2.6” 10.2 ± 3.4”

120 9.0 ± 0.7 7.8 ± 3.9 7.3 ± 2.6” 8.6 ± 3.3”

144 6.2 ± 3.2 7.5 ± 0.9 7.5 ± 2.2 7.7 ± 3.3

* Values are means ± SD. Significance is indicated by:

a, P

< .05;

b, P

< .01. Blank spaces indicate that there were no infants in that fluid group for that day.

TABLE

8.

Relation

of Daily

Mean

Total

Serum

Bilirubin

Level

to Oral Caloric

Inta

of 2,000

to 2,499

Grams,

by Phototherapy

(P) and Control

(C) Groups*

ke for Infants

with

Birth

Weight

Hours Into Subgroup A Subgroup B

Study (<60 Calories/kg/24 h) (60-90 Calories/kg/24 h)

Subgroup C (>90 Calories/kg/24 h)

P C

P C P C

0 12.3 ± 2.0 12.0 ± 2.6 12.6 ± 1.8 13.1 ± 2.1

24 12.0 ± 3.4 13.3 ± 3.4 10.9 ± 1#{149}6b 13.5 ± 1.8”

48

11.1

±

4.1

14.4 ± 3.6 9.4 ± 2.6” 13.7 ± 2.8”

72 9.4 ± 3.6 13.5 ± 3.4 7.0 ± 2.2” 13.3 ± 40b

96

8.8

± 4.1 9.9 ± 3.4 6.8 ± 2.5 11.4 ± 2.4

120 6.4 ± 1.7 10.5 ± 2.9

144 8.7 9.3 ± 2.0 7.2 ± 3.7 10.0 ± 2.3

11.9 ± 1.8 12.4 ± 1.8

10.1 ± 2.4” 13.0 ± 2#{149}6b

8.5 ± 19b 13.3 ± 3.Ob

7.6 ± 2.4” 11.6 ± 2.6”

6.6 ± 2.3” 10.6 ± 3.0”

6.5 ± 2.5” 9.6 ± 2#{149}9b

6.4 ± 2.3b 8.5 ± 2.6”

*

Values

are means

±

SD. Significance

is indicated

by: b, P

< .01. Blank spaces indicate that there were no infants in

that

fluid

intake

group

for that

day.

TABLE

9.

Relation

of Daily

Mean

Total

Serum

Bilirubin

Level

to Oral Caloric

Inta

2,500 Grams, by Phototherapy (P) and Control (C) Groups*

ke for Infants

with

Birth

Weight

Hours Into Subgroup A Subgroup B

Study (<60 Calories/kg/24 h) (60-90 Calories/kg/24 h)

Subgroup C (>90 Calories/kg/24 h)

P C P C P C

0 15.3 ± 2.5 15.9 ± 2.1 15.9 ± 2.2 15.6 ± 2.7

24 13.3 ± 2.8” 17.2 ± 2#{149}8b 13.6 ± 2#{149}6b 15.1 ± 2.8”

48 10.8 ± 4.1 13.5 ± 3.8 11.3 ± 2.8” 14.0 ± 2#{149}8b

72 8.0 ± 3.8 13.2 ± 3.0 8.8 ± 3.3” 12.1 ± 3.6”

96 6.1 ± 2.0 14.5 ± 3.3 7.5 ± 2.8b 10.9 ±

3.0”

120 8.8 ± 0.0 10.4 ± 0.0 7.4 ± 2.3 8.0 ± 3.9

144 7.4 ± 3.8 6.6 ± 0.0 6.9 ± 2.3 8.0 ± 2.9

16.3 ± 2.2 15.6 ± 2.1

13.4 ± 2.5” 14.7 ± 2#{149}7b

10.8 ± 2.7” 13.0 ± 3.0”

9.2 ± 2.8” 11.7 ± 3.2”

7.9

± 2.5” 10.0 ± 3.4”

7.3 ± 3.3” 8.6 ± 3.3”

7.6 ± 2.3 7.7 ± 3.3

(6)

* References 6, 27, 28, 35, 42, 77, 93, 103, 107.

432

PHOTOTHERAPY

FOR

NEONATAL

HYPERBILIRUBINEMIA

Body

Weight.

Light-treated

infants

tended

to lose

more

weight

during

the

first

two

days

of

photother-apy

than

control

infants.

However,

the

trend

in

weight

change

was

less

consistent

than

with

group

1

infants.

Again,

this

may

be due

to

the

fact

that

infants in

this

group

were

more

mature

and

entered

the

study

at the

third

or fourth

postnatal

day

when

many

of them

would

already

have

started

to gain

weight.

DISCUSSION

The

data

from

this

study

indicate

that

higher

fluid

intake

tended

to

be

associated

with

lower

serum

bilirubin

levels

in

both

control

and

light-treated

infants.

Conceivably,

good

hydration

may

lower

serum

bilirubin

concentration

by dilution,

but

this

minimal

effect

cannot

explain

the

magnitude

of the

changes.

It

is also

possible

that

increased

fluid

intake

may

improve

blood

flow

and

urinary

secretion

by

improving

water

balance,

leading

to

excretion

of water-soluble

bilirubin

fractions.

Stud-ies

by

Edgren

and

Wester26

have

shown

that

the

glomerular

filtration

rate

is decreased

during

fast-ing.

In adults,

this

diminished

renal

function

may

account

for about

20%

of the

observed

rise

in serum

bilirubin level with starvation.7 Phototherapy was

not

associated

with

lower

serum

bilirubin

levels

in

infants

who

received

fluids

in amounts

less

than

60

mL/kg/24

h, but

was

associated

with

lower

serum

bilirubin

levels

when

fluid

intake

was

in excess

of

this amount.

The

water-soluble

bilirubin

products

resulting

from

phototherapy

may

also

be

excreted

in

the

urine.40

Limited

fluid

intake

alone

cannot

account

for

the

decreased

efficiency

of

photother-apy

because

these

infants

are

more

likely

to

have

limited

caloric

intake

as well.

The

data

from

our

present

study,

suggesting

that

an

inverse

relation

exists

between

caloric

intake

and

serum

bilirubin

concentration

in

control

in-fants, support previous observations

on the

role

of

caloric

intake

on lowering

serum

bilirubin.*

The

mechanisms

of

the

association

of

higher

bilirubin

levels

with

fasting

are

unclear.

Increased

bilirubin

production

and

decreased

hepatic

biliru-bin

clearance

have

been

suggested

as possibilities.

Earlier

studies565

indicated

that

fasting

or

insulin-induced

hypoglycemia

produced

a marked

increase

in

the

activity

of

heme

oxygenase,

producing

an

increase

in hepatic

heme

turnover

and

leading

to

increased

bilirubin

production.

However,

studies

in

animals’2

and

newborn

infants,94

using

the

excre-tion

rate

of endogenously

produced

carbon

mon-oxide

as an

index

of bilirubin

production,

failed

to

demonstrate

any

increase

due

to

caloric

depriva-tion.

Studies

by

Bloomer

et

al’2

suggest

that

hepatic

bilirubin

clearance

may

be decreased

during

fasting.

Further,

the

rise

in level

of nonesterified

fatty

acid

(NEFA)

associated

with

fasting

may

play

an

im-portant

role

in

this

process.

The

elevated

NEFA

level

may

act

through

several

mechanisms:

(1)

NEFA

may

interfere

with

receptors

on the

hepatic

cell

membrane

that

interact

with

the

albumin

mol-ecule

to

separate

bilirubin,

and

thereby

diminish

hepatic

bilirubin

uptake.’3

Because

NEFA

com-petes

with

unconjugated

bilirubin

for

binding

by

the

Y-protein

(ligandin)

and

Z-protein

in the

cyto-plasm

of

liver

cells,29’59’7’

the

increase

in

NEFA

during

caloric

deprivation

may,

therefore,

interfere

with

intracellular

transport.

(3)

NEFA

may

de-crease

hepatic

bilirubin

clearance

by inhibiting

ur-idine

diphosphate

(UDP)-glucuronyl

transferase

activity.

This

has

been

demonstrated

in vitro”

and

in vivo

in starved

rats.77

Additionally,

Felsher

and

Carpio27

reported

that

patients

with

the

Gilbert

syndrome

and

reduced

hepatic

UDP-glucuronyl

transferase

activity

showed

a greater

increase

in

total

bilirubin

during

caloric

restriction

than

do

normal

subjects.

Thus,

there

are

several

mecha-nisms

through

which

NEFA

may

increase

uncon-jugated

serum

bilirubin

level

during

caloric

depri-vation

or restriction.

Another

mechanism

for

the

increase

in

serum

bilirubin

levels

during

restriction

of

oral

caloric

intake

may

be related

to the

enterohepatic

shunting

of bilirubin.’#{176}#{176}

Studies

by Wu

et al’#{176}7

showed

that

early

caloric

intake

facilitated

early

passage

of

me-conium, with resultant

decrease

of

absorption

of

bilirubin

back

into

circulation.

Studies

by Gartner

and

Lee32

in adult

rats

indicated

that

caloric

dep-rivation

without

thirsting

markedly

increased

in-testinal

absorption

of unconjugated

bilirubin.

This

effect

was

reversed

by intravenous

glucose

admin-istration.32

These

investigators

have

also

found

that

certain

nonesterified

fatty

acids

administered

intra-duodenally

inhibit

intestinal

absorption

of bilirubin

whereas

others

increase

it, suggesting

that

different

fat

blends

in formulas

may

promote

or retard

the

reabsorption

of bilirubin.

Thus,

caloric

intake

may

alter

the

level

of

serum

bilirubin

through

both

systemic

and

enteric

pathways.

It is now

thought

that

phototherapy

causes

pho-tochemical

excitation

of

bilirubin

which

decays

back

to bilirubin,

or after

isomerization,

to

geomet-nc

isomers

of

bilirubin.

These

isomers

migrate

through

the

plasma

membrane

into

the

blood;

the

isomers

then

become

bound

to

albumin

and

are

extracted

from

blood

into

hepatocytes.#{176}’61’’69’70’95

Even

though

the

bilirubin

conjugating

system

may

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(7)

not

be functioning

adequately

during

the

first

few

days

of life,

the

more

polar

water-solvated

photo-isomers,

which

do

not

require

conjugation

for

ex-cretion,

will

be excreted

in the

bile.

In addition

to

being

more

polar

and

more

hydrophilic

than

the

natural

bilirubin,6’

the

photoisomers

are

thermo-dynamically

less

stable

than

bilirubin

and

revert

readily

to bilirubin

when

warmed

or irradiated

in

solution.6’

This

reversion

phenomenon

has

clinical

relevance

in view

of previous

reports

that

the

re-version

product,

bilirubin,

and

its

isomers,

cause

decreased

intestinal

transit

time,”#{176} decreased

nu-trient

and

water

absorption,75”#{176}and

loose

stools

by

inhibiting

intestinal

lactase.4’’89

The

tendency

ob-served

in

this

study

for

infants

receiving

photo-therapy

to have

more

frequent

stools

supports

the

findings

in previous

studies,

and

may

be explained

by the

presence

of bilirubin

isomers

in the

intestine

in the

light-treated

infants.

Additionally,

the

bili-rubin

isomers

might

be

reabsorbed

into

the

circu-lation

from

the

intestine,

which

would

reduce

the

overall

efficiency

of its removal.

Higher

oral

caloric

feeding,

by

promoting

peristaltic

movements

and

early

passage

of stools,’#{176}7would

tend

to remove

the

bilirubin

and

its

isomers

and

decrease

their

reab-sorption,

thus

increasing

the

efficiency

of

photo-therapy.

The

factors

discussed

above

would

appear

to be

most

evident

in infants

in

group

1. In

infants

in

groups

2 and

3, the

association

of these

factors

with

lowering

of bilirubin

level

is less

evident.

This

may

be partly

due

to the

design

of the

protocol.

In the

groups

of infants

with

greater

weight,

many

of the

infants

entered

the

study

after

their

serum

bilirubin

level

had

peaked.

In

addition,

their

conjugation

system

would

be

more

mature

and

function

more

adequately.

These

two

factors

would

tend

to

hide

some

of the

overt

association

between

caloric

intake

and

bilirubin

levels

observed

in infants

in group

1.

CONCLUSION

The

influence

of fluid

and

caloric

intake

on

neo-natal

jaundice

and

efficacy

of

phototherapy

was

evaluated.

Results

indicate

that

overall,

higher

fluid

and

caloric

intake

were

associated

with

lower

daily

mean

serum

bilirubin

level

in both

phototherapy-treated

and

control

infants.

This

association

was

stronger

with

increased

calories

than

with

increased

fluids,

and

primarily

was

dependent

on oral

caloric

intake.

The

inverse

correlation

between

oral

caloric

intake

and

serum

bilirubin

level

was

more

marked

in infants

in the

lowest

birth

weight

group

(< 2,000

g) in which

phototherapy

was

used

to prevent

hy-perbilirubinemia.

The

caloric

effect

was

less evident

in

infants

in

the

higher

birth

weight

groups

and

when

phototherapy

was

used

to

treat

established

hyperbilirubinemia.

(8)

SUPPLEMENT

439

used

in

the

clinical

trial

of phototherapy

demon-

considered

reliable.

Problems

such

as

these

must

strated

potential

for

efficiently

obtaining

light

ex-

be resolved

before

the

photodosimeter

system

could

posure

data

integrated

over

time

for a large

number

reach

widespread

clinical

usefulness.

of

infants.

However,

because

of variation

in

per-formance

of the

badge

and

probable

deterioration

in

some

badges

over

time,

the

system

cannot

yet

be

REFERENCES

(see

page

439)

References

1. Albrecht RM, Roney PL: Phototherapy for neonatal hy-perbilirubinemia: A survey of US hospitals in 1974, in

Symposium on Biological Effects and Measurement of Light Sources. DHHS publication No. (FDA) 81-8156, 1981, pp 55-68

2. Allen FH Jr, Diamond LK: Erythroblo.stosis Fetalis. Boston, Little, Brown and Co, 1957

3. Arkans HD, Cassady G: Estimation of unbound serum bilirubin by peroxidase assay method: Effect of exchange transfusion on unbound bilirubin and serum bindings. J Pediatr 1978;92:1001-1005

4. Bakken AF: Temporary intestinal lactase deficiency in light-treated jaundiced infants. Acta Paediatr Scand

1977;66:91-96

5. Bakken AF, Thaler MM, Schmid R: Metabolic regulation of heme catabolism and bilirubin production: I. Hormonal control of hepatic heme oxygenase activity. J Clin Invest

1972;51:530-536

6. Barrett PVD: Effects of caloric and noncaloric materials in fasting hyperbilirubinemia. Gastroenterology 1975;68: 361-369

7. Barrett PVD: Hyperbilirubinemia of fasting. JAMA

1971;217:1349-1353

8. Battaglia FC, Lubchenco LO: A practical classification of newborn infants by weight and gestational age. J Pediatr

1967;71:159

9. Behrman RE, Brown AK, Currie MR, et al: Preliminary report of the committee on phototherapy in the newborn infant. J Pediatr 1974;84:135-143

10. Behrman RE (chairman): Final Report of the Committee on Phototherapy in the Newborn. National Academy of Sciences, Washington, DC, 1974

11. Bevan BR, Holton JB: Inhibition of bilirubin conjugation in rat liver slices by free fatty acids, with relevance to the

problem of breast milk jaundice. Clin Chim Acta

1972;41:101-107

12. Bloomer JR, Barrett PV, Rodkey FL, et al: Studies on the mechanism of fasting hyperbilirubinemia. Goat roenterology

1971;61:479-487

13. Bloomer JR, Berk PD, Vergalla J, et al: Influence of albumin on the hepatic uptake of unconjugated bilirubin.

Clin Sci 1973;45:505-516

14. Boggs TR, Westphal MC: Mortality of exchange transfu-sion. Pediatrics 1960;26:745-755

15. Bratlid D: Reserve albumin binding capacity, salicylate saturation index, and red cell binding of bilirubin in neo-natal jaundice. Arch Dis Child 1973;48:393-397

16. Brown AK, Kim MH, Wu PYK, et al: Efficacy of photo-therapy in prevention and management of neonatal hyper-bilirubinemia. Pediatrics 1985;75(suppl):393-400

17. Brown AK, McDonagh AF: Phototherapy for neonatal hyperbilirubinemia: Efficacy, mechanism and toxicity. Adv Pediatr 1980;27:341-389

18. Bryla DA: Development, design, and sample composition.

Pediatrics 1985;75(suppl):387-392

19. Cashore WJ, Gartner LM, Oh W, et al: Clinical application

of neonatal bilirubin-binding determinations: Current sta-tus. J Pediatr 1978;93:827-.832

20. Cashore WJ, Karotkin EH, Stern L, et al: The lack of effect of phototherapy on serum bilirubin-binding capacity in newborn infants. J Pediatr 1975;87:977-980

21. Chan G, Schiff D, Stern L: Competitive binding of free fatty acids and bilirubin to albumin: Differences in HBABA dye versus Sephadex G-25 interpretation of results. Clin Biochem 1971;4:208-214

22. Cremer RJ, Parryman PW, Richards DH: Influence of light on the hyperbilirubinemia of infants. Lancet 1958;1:1094-1097

23. Dalton J, Milgrom LR, Bonnett R: Luminescence of bili-rubin. Chem Phys Lett 1979;61:242-244

24. Doumas BT, Biggs HG: Determination of serum albumin, in Cooper GR (ed): Standard Methods of Clinical Chemis-try. New York, Academic Press, 1972, pp 175-188 25. Dubowitz LMS, Dubowitz V, Goldberg C: Clinical

assess-ment of gestational age in the newborn infant. J Pediatr

1970;77:1-10

26. Edgren B, Wester P0: Effect of starvation on renal func-tion. Lancet 1970;1:613-614

27. Feisher BF, Carpio NM: Caloric intake and unconjugated hyperbilirubinemia. Gostroenterology 1975;69:42-47

28. Felsher BF, Rickard D, Redeker AG: The reciprocal rela-tion between caloric intake and the degree of hyperbili-rubinemia in Gilbert’s syndrome. N EngI J Med 1970; 283:170-172

29. Foliot A, Housset E, Ploussard JP, et al: Study of Y and Z, two cytoplasmic bilirubin binding proteins: Their devel-opment in the liver of fetal and newborn Wistar and Gunn rats. Biomedicine 1973;19:488-491

30. Friedman L, Lewis PJ, Clifton P, et al: Factors influencing the incidence of neonatal jaundice. Br Med J 1978;1:1235-1237

31. Friederiszich FK: “Co-twin control” study of the long-term effects of phototherapy, in Brown AK, Showacre J (eds):

Phototherapy for Neonatal Hyperbilirubinemia. Long-Term Implications. DHEW publication No. (NIH) 76-1075, 1976, pp 111-122

32. Gartner LM, Lee KS: Effect of starvation and milk feed-ing on intestinal bilirubin absorption. Gastroenterology

1979;77:A13

33. Gartner LM, Lee K, Keenan WJ, et al: Effect of photo-therapy on albumin binding of bilirubin. Pediatrics

1985;75(suppl):401-406

34. Gartner LM, Zarafu I, Kwang SL, et al: Prophylactic use of phototherapy in low-birth-weight infants: Experience with a controlled clinical trial pilot study, in Brown AK, Showacre J (eds): Phototherapy for Neonatal Hyperbiliru-binemia: Long-Term Implications. DHEW publication No. (NIH) 76-1075, 1976, pp 71-93

35. Gilbert A, Herscher M: Surles variations de la cholemie physiologique. Presse Med 1906;14:209-21 1

36. Giunta F, Rath J: Effect of environmental illumination in prevention of hyperbilirubinemia of prematurity.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(9)

rics1969;44:162-167

37. Glass L: Thermal effects of the bilirubin reduction lamp, in Proceedings of the American Pediatric Society Meeting,

Atlantic City, NJ, 1969, p 51

38. Gruenwald P: Infants of low birth weight among 5,000 deliveries. Pediatrics 1964;34:157-162

39. Hegyi T, Hiatt IM, Vogl TP, et al: Use of the Beckman film badge for monitoring during phototherapy. J Pediatr

1976;89:473-474

40. Heirwegh KPM, Van Hess GP, Blanckaert N, et al: Com-parative studies on the structure of conjugated bilirubin IX- and changes in cholestasis, in Taylor W (ed): The Hepatobiliary System. New York, Plenum Press, 1976, pp 339-354

41. Hodgman JE, Schwartz A: Phototherapy and hyperbiliru-binemia of the premature. Am J Di.s Child 1970;119:473-477

42. Hubbell JP, Drorbaugh JE, Rudolph AJ, et al: “Early” versus “late” feeding of infants of diabetic mothers. N EngI

J Med 1961;265:835-837

43. Humbert JR, Abelson H, Hathaway WE, et al: Polycythe-mia in small for gest.ational age infants. J Pediatr

1969;75:812-819

44. Jendrassik K, Grof P: Vereinfachte photometrische

meth-oden zur Bestimmung des Blut-Bilirubins. Biochem Z

1939;297:81

45. Johnson L, Boggs TR: Bilirubin-dependent brain damage: Incidence and indications for treatment, in Odell GB, Schaffer R, Simopoulous AP (eds): Phototherapy in the Newborn: An Overview. Washington, DC, National Acad-emy of Sciences, 1974, pp 122-149

46. Kapitulnik J, Kaufmann NA, Alayoff A, et al: Character-istics of a photo-product of bilirubin found in vitro and in vivo, and its effect on bilirubin binding affinity of serum, in Bergsma DL, Blondheim SH (eds): Bilirubin Metabolism in the Newborn. New York, American Elsevier, 1976, vol 2, pp 53-60

47. Kapitulnik J, Kaufmann NA, Blondheim SH, et al: Effect of light on bilirubin binding by serum, in Brown AK, Showacre J (eds): Phototherapy for Neonatal Hyperbiliru-binemiw Long-Term Implications. DHEW publication No.

(NIH) 76-1075, 1976, pp 191-197

48. Kapitulnik J, Valaes T, Kaufmann NA, et al: Clinical evaluation of sephadex gel filtration in the estimation of bilirubin binding in serum in neonatal jaundice. Arch Dis Child 1974;49:886

49. Kaplan E, Herz F, Scheye E, et al: Phototherapy in ABO hemolytic disease of the newborn infant. J Pediatr

1971;79:91 1

50. Karabus CD: Phototherapy of neonatal jaundice at a gen-eral children’s hospital, in Brown AK, Showacre J (eds):

Phototherapy for Neonatal Hyperbilirubinemia: Long-Term Implications. DHEW publication No. (NIH) 76-1075, 1976, pp 95-110

51. Keenan WJ, Novak KK, Sutherland JM, et al: Morbidity and mortality associated with exchange transfusion. Pedi-atrics 1985;75(suppl):417-421

52. Kitchen WH: Neonatal mortality in infants receiving an exchange transfusion. Aust Paediatr J 1970;6:30-40

53. Landry BA, Anderson FA: Optical radiation measurements: Instrumentation and source of error. J NatI Cancer Inst

1982;69:155-161

54. Landry R4J, Scheidt PC, Hammond RW: Ambient light and phototherapy conditions of eight neonatal care units: A summary report. Pediatrics 1985;75(suppl):434-436

55. Lee KS, Gartner LM: Bilirubin binding by plasma proteins: A critical evaluation of methods and clinical implications, in Scarpelli EM, Cosmi EV (eds): Reviews in Perinatal Medicine. New York, Raven Press, 1978, pp 319-343 56. Lee KS, Gartner LM, Vaisman SL: Measurement of

bili-rubin-albumin binding: I. Comparative analysis of four methods and four human serum albumin preparations.

Pediatr Res 1978;12:301-307

57. Lester R, Schmid R: Intestinal absorption of bile pigments: I. The enterohepatic circulation of bilirubin in the rat. J

Clin Invest 1963;42:736-746

58. Lester R, Schmid R: Intestinal absorption ofbile pigments:

II. Bilirubin absorption in man. N EngI J Med

1963;269:178-182

59. Levi AJ, Gatmaitan Z, Arias IM: Two hepatic cytoplasmic protein fractions, Y and Z, and their possible role in the hepatic uptake of bilirubin, sulfobromophthalein and other anions. J Clin Invest 1969;48:2156-2167

60. Lightner DA, Wooldridge TA, McDonagh AF: Photobili-rubin: An early bilirubin photoproduct detected by absorb-ance difference spectroscopy. Proc NatI Acad Sci USA

1979;76:29-32

61. Lightner DA, Wooldridge TA, McDonagh AF: Configura-tional isomerization of bilirubin and the mechanism of jaundice phototherapy. Biochem Biophys Res Commun

1979;86:235-243

62. Lubchenco LO: Assessment of gestational age and devel-opment at birth. Pediatr Clin North Am 1970;17:125-145 63. Lubchenco LO, Searls DT, Brazie JV: Neonatal mortality

rate: Relationship to birth weight and gestational age. J Pediatr 1972;81:814-822

64. Lucey JF, Ferreiro M, Hewitt J: Prevention of hyperbili-rubinemia of prematurity by phototherapy. Pediatrics

1968;41:1047-1054

65. Lundh B, Johansson B, Mercke C: Enhancement of heme catabolism by caloric restriction in man. Scand J Clin Lab

Invest 1963;42:1300-1312

66. Mantel N: Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer

Chem-other Rep 1966;50:163-170

67. Maurer HM, Kirkpatrick BV, McWilliams NB, et al: Pho-totherapy for hyperbilirubinemia of hemolytic disease of the newborn. Pediatrics 1985;75(suppl):407-412

68. McDonagh AF, Lightner DA, Wooldridge TA: Geometric isomerization of bilirubin IXa and its diethyl ester. JCS

Chem Comm 1979;110-112

69. McDonagh AF, Palma LA, Lightner DA: Blue light and bilirubin excretion. Science 1980;208:145-151

70. McDonagh AF, Ramonas LM: Jaundice phototherapy: Mi-cro flowcell photometry reveals rapid biliary response of Gunn rats to light. Science 1978;201:829-831

71. Ockner RK, Manning JA, Poppenhausen RB, et al: A

binding protein for fatty acids in cytosol of intestinal mucosa, liver, myocardium and other tissues. Science

1972;177:56-58

72. Odell GB, Brown RS, Holtzman NA: Dye-sensitized pho-tooxidation of albumin associated with a decreased capacity for protein-binding of bilirubin. Birth Defects 1970;6:31-35 73. Odell GB, Storey GNB, Rosenberg LA: Studies in

kernic-tents: III. The saturation of serum proteins with bilirubin during neonatal life and its relationship to brain damage at five years. J Pediatr 1971;76:12-21

74. Ogawa J, Ogawa Y, Onishi 5, et al: Five years’ experience in phototherapy, in Brown AK, Showacre J (eds): Photo-therapy for Neonatal Hyperbilirubinemia: Long-Term Im-plications. DHEW publication No. (NIH) 76-1075, 1976, pp 49-66

75. Oh W, Karecki H: Phototherapy and insensible water loss in newborn infant. Am J Dis Child 1972;124:230-232

76. Oh W, Yao AC, Hanson JS, et al: Peripheral circulatory response to phototherapy in newborn infants. Acta Poe-diatr Scand 1973;62:49-54

77. Owens D, Sherlock 5: Diagnosis of Gilbert’s syndrome: role of reduced caloric intake tests. Br Med J 1973;3:559-563 78. Panagopoulos G, Valaes T, Doxiadis SA: Morbidity and

mortality related to exchange transfusions. J Pediatr

1969;74:247-254

79. Patel DA, Pildes RS, Behrman RE: Failure of phototherapy to reduce serum bilirubin in newborn infants. J Pediatr

1970;77:1048-1051

80. Peevy K, Wiseman HJ: ABO hemolytic disease of the

newborn: Evaluation of management and identification of racial and antigenic factors. Pediatrics 1978;61:475-478 81. Perl H, Nijjar A, Ebara H, et al: Bilirubin toxicity without

(10)

SUPPLEMENT

441

82. Porter EG, Waters WJ: A rapid micromethod for measur-ing the reserve albumin binding capacity in serum from newborn infants with hyperbilirubinemia. J Lab Clin Med 1966;67:660-668

83. Porto S, Hsia DY: Mechanism of blue light on neonatal jaundice. J Pediatr 1969;74:812-813

84. Porto SO, Pildes RS, Goodman H: Studies on the effect of phototherapy on neonatal hyperbilirubinemia among low birth weight infants: II. Protein binding capacity. J Pediatr 1969;75:1048

85. Rubaltelli FF, Largajolli G: Effect of light exposure on gut transit time in jaundiced newborns. Acta Paediatr Scand 1973;62:146-148

86. Scheidt PC, Mellits ED, Hardy JB, et al: Toxicity to bilirubin in neonates: Infant development during first year in relation to maximum neonatal serum bilirubin concen-tration. J Pediatr 1977;91:292-297

87. Schiff D, Aranda J, Chan G, et al: Metabolic effects of exchange transfusion: I. Effect of citrated and of heparin-ized blood on glucose, nonesterified fatty acids, 2-(4 hy-droxybenzeneazo) benzoic acid bindings, and insulin. J Pediatr 1971;78:603-609

88. Seem E, Wille L: Salicylate saturation index in neonatal jaundice. Biol Neonate 1975;26:67-75

89. Sisson TR: Advantages of a lactose-free formula for jaun-diced infants undergoing phototherapy. In Bachhuber WL, Benson JD, Dame MC, et al (eds): Proceedings of Ross

Clinical Research Conference: Low-Birth- Weight Infants

Fed Isomil. Columbus, OH, Ross Laboratories, 1979, pp

101-107

90. Sisson T: Discussion, in Bilirubin metabolism in the new-born. Birth Defects 1970;6:36

91. Sisson TRC, Kendall N, Glauser SC, et al: Phototherapy ofjaundice in newborn infants: I. ABO blood group incom-patability. J Pediatr 1971;79:904-910

92. Sliney DH, Wolbarsht ML: Safety with Lasers and Other

Optical Sources: A Comprehensive Handbook. New York,

Plenum Press, 1980

93. Smallpiece V, Davies PA: Immediate feeding of premature infants with undiluted breast-milk. Lancet

1964;2:1349-1352

94. Stevenson DK, Bartoletti AL, Ostrander CR, et al: Effect of fasting on bilirubin production in the first postnatal week. Clin Res 1980;1:126A

95. Stoll MA, Zenone EA, Ostrow JD, et al: Preparation and properties of bilirubin photoisomers. Biochem J 1979; 183:139-146

96. Svenningsen NW, Lindquist A: HBABA index in neonatal jaundice, in: Proceedings of the XIIIth International

Con-gress of Pediatrics, Vienna, Austria, 1971, vol 1, p 305

97. Tan KL: Phototherapy for neonatal hyperbilirubinemia in “healthy” and “ill” infants. Pediatrics 1976;57:836-838

98. Tan KL: The influence of gestational age and birth weight on the infant response to phototherapy for neonatal hy-perbilirubinaemia. Aust Paediat J 1977;13:22-24

99. Teberg A, Hodgman JE, Wu PYK, et al: Recent improve-ment in outcome for the small premature infant. Clin

Pediatr 1977;16:307-313

100. Ulstrom RA, Eisenklam E: The enterohepatic shunting of bilirubin in newborn infant. J Pediatr 1974;65:27-37 101. Warkany J, Monroe BB, Sutherland BS: Intrauterine

growth retardation. Am J Dis Child 1961;102:249-279 102. Weldon VV, Odell GB: Mortality risk of exchange

trans-fusion. Pediatrics 1968;41:797-801

103. Wennberg RP, Schwartz R, Sweet AY: Early versus delayed feeding of low birth weight infants: Effects of physiologic jaundice. J Pediatr 1966;68:860-866

104. Wong YK, Wood BSB: Relative roles of phototherapy and phenobarbitone in treatment of nonhaemolytic neonatal jaundice. Arch Dis Child 1973;48:704-708

105. Wu PYK, Hodgman JE: Insensible water loss in preterm infants: Changes with postnatal development and non-ionizing radiant energy. Pediatrics 1974;54:704-712

106. Wu PYK, Moosa AS: Effect of phototherapy on nitrogen and electrolyte levels and water balance in jaundiced pre-term infants. Pediatrics 1978;61:193-198

107. Wu PYK, Teilman P, Gabler M, et al: “Early” versus “late” feeding of low birth weight neonates: Effect on serum bilirubin, blood sugar, and responses to glucagon and epi-nephrine tolerance tests. Pediatrics 1967;39:733-739

108. Wu PYK, Wong WH, Hodgman JE, et al: Changes in blood flow in the skin and muscle with phototherapy. Pediatr Res 1974;8:257-262

109. Wu PYK, Hodgman JE, Kirkpatrick BV, et al: Metabolic aspects ofphototherapy. Pediatrics 1985;75(suppl):427-433 110. Yerushalmy J: The classification of newborn infants by

birth weight and gestational age. J Pediatr 1967;71:164-172

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(11)

1985;75;427

Pediatrics

A. Bryla

Paul Y. K. Wu, Joan E. Hodgman, Barry V. Kirkpatrick, Nathaniel B. White, Jr and Dolores

Metabolic Aspects of Phototherapy

Services

Updated Information &

http://pediatrics.aappublications.org/content/75/2/427

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

(12)

1985;75;427

Pediatrics

A. Bryla

Paul Y. K. Wu, Joan E. Hodgman, Barry V. Kirkpatrick, Nathaniel B. White, Jr and Dolores

Metabolic Aspects of Phototherapy

http://pediatrics.aappublications.org/content/75/2/427

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1985 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

References

Related documents

According to our conceptual framework inspired by Zollo and Winter ’ s ( 2002 ) deliber- ate learning model, the investments in the three learning mechanisms, i.e.,

In order to test how students are in fact engaging in academic argumentation for the purposes of learning in online discussion forums, we turn to Clark &amp; Sampson (2007) and

Conclusion: In this study Association was seen between the duration of disease, age and nutritional status (BMI and Preoperative Albumin level) of empyema patient with clinical

The cells with positive expression of the CADM1 protein in normal esophageal tissues showed the presence of brown granules in the cytoplasm, and the cells with positive reaction

For example, a strong credit risk management framework will include the following indicators the board of directors and senior management ’ s tolerance for risk is

Do the three training periods (general preparatory period, special preparatory period, competitive peri- od), when consecutive, induce significant changes in the physiological

Partially automated cloud/shadow removal and land cover change detection using satellite imagery study described multi- platforms and multi-temporal satellite data

Clark’s book helps make sense of this, by making clear in a host of different ways how the brain is best viewed as a shifting collection of opportunistic control systems, ever-ready